Wentzville R-IV School District
Payroll Reimbursement Form
Employee Name:
Building:
Payroll Period
From Date:
Last 4 SS#
To Date:
(Please use the Payroll Calendar on our website under "Departments" and "Benefits/Payroll")
Date
Start Time Stop Time Hours
Date
Start Time
Stop Time
Total Hr / Day
Pay Rate
Total to Pay
Service Provided
Activity Worker
Curriculum Development
Detention
Driver Education
Homework Assist/Tutoring
SPED Training
Other
Homebound child:
Parent signature verifying homebound hours:
Account Code:
The above is a correct listing of the days of service provided during the payroll dates reported.
Employee Signature:
Date:
Administrator Approval:
Date:
Revised 7/10
Hours